Bleeding between periods - Intermenstrual Bleeding

Definition

Intermenstrual bleedingis vaginal bleeding (other than post-coital) at any time during the menstrual cycle other than during normal menstruation.

Bleeding between periods (intermenstrual bleeding) may be associated with sexual intercourse - bleeding during intercourse or
post coital bleeding) or may occur spontaneously. It is a frequently encountered symptom - 17% per annum
0401

Bleeding between periods may be in the middle of the menstrual cycle - mid cycle bleeding or mid cycle spotting.

Bleeding between periods is one example of gynaecological abnormal bleeding.

Women on the
pill may experience break through bleeding. This is not strictly intermenstrual bleeding because the monthly bleeding experienced by those women taking the pill is correctly called 'withdrawal bleeding' and is not spontaneous
menstruation. Usually, mid cycle bleeding amounts to no more than a little mid cycle spotting. When mid cycle bleeding is accompanied by lower abdominal or pelvic pain it is known as "Mittelschmerz".

Intermenstrual bleeding may amount to no more than spotting between periods or it may be heavy.

Bleeding between periods may be misinterpreted as irregular menstruation (irregular periods).

When intermenstrual bleeding is reported, care should be taken to exclude pregnancy bleeding -
threatened miscarriage or ectopic pregnancy.

How is intermenstrual bleeding Investigated?

Although worrying for many women, bleeding between periods is relatively rarely associated with sinister conditions. However, as cervical cancer and endometrial cancers can present with intermenstrual bleeding, it is imperative that they be excluded.

Determine that the bleeding is from the vagina, not the rectum or in the urine. Any doubt can be eliminated by inserting a tampon which will confirm presence of blood in the vagina.

Investigations

Other possible investigations include:

Blood tests:

FBC

Clotting

Thyroid function

Infection Screen:

Bacteriology Swabs

Chlamydia Swabs

Transvaginal ultrasound - Ultrasound should ideally be done immediately postmenstrually as the endometrium at its thinnest and polyps and cystic areas tend to be more obvious. An endometrial thickness of 8 mm or less is significantly less likely to be associated with a malignant pathology.0602

Endometrial biopsy - Endometrial biopsy may be done as a surgery or clinic-based procedure using the Pipelle device or Vabra aspirator.

Hysteroscopy -
Hysteroscopy with biopsy is the current gold-standard for investigating the uterine cavity, allowing direct visualisation and tissue diagnosis. In many centres, it can be done as a clinic procedure.

How is intermenstrual bleeding Managed?

Management depends on the cause of the bleeding:

If gynaecological cancer is suspected, refer urgently for investigation. Do not wait on the results of a smear test or be deterred by a previous negative result where clinical suspicion is high.

Cervical erosion - ectropions:

May resolve if the COCP is stopped or following pregnancy

Can be treated conservatively

If treatment is desired, options include thermal cautery and diathermy, cryosurgery, laser or microwave therapy.

Cervical polyps:

Avulse and send for histology

They are accompanied by endometrial polyps in about 25%,0701 - further investigation (ultrasound +/- hysteroscopy), particularly in older women, can be indicated.

Dysfunctional uterine bleeding (DUB) is the most common cause of abnormal vaginal bleeding (usually
heavy periods) during a woman's reproductive years. However, it is a diagnosis of exclusion and should only be diagnosed after pregnancy, iatrogenic and systemic causes and genital tract pathology have been excluded.1 It is most common at the extremes of reproductive life, in the pubertal and perimenopausal phases and is associated with anovulatory cycles in 70% of cases and, in these cases, is caused by
endometrial hyperplasia.

This is the personal website of David A Viniker MD FRCOG, retired Consultant Obstetrician and Gynaecologist - Specialist Interests - Reproductive Medicine including Infertility, PCOS, PMS, Menopause and HRT.I do hope that you find the answers to your women's health questions in the patient information and medical advice provided.

I do hope that you find the answers to your women's health questions in the patient information and medical advice provided.

The aim of this web site is to provide a general
guide and it is not intended as a substitute for a consultation
with an appropriate specialist in respect of individual care and
treatment.

David Viniker retired from active clinical practice in 2012. In 1999, he setup this website - www.2womenshealth.com - to provide detailed
information many of his patients requested. The website attracts thousands of visitors every day from around the world.If you would like advice on how to make more from your website, please visit his website Keyword SEO PRO or email him on david@page1-on-google.com.